1. WHO’s cervical cancer screening programmes: managerial guidelines by Naila Baig Ansari Research Fellow Dept. of Community Health Sciences The Aga Khan University Karachi, Pakistan

2. Who am I? Education: MSc (Epidemiology), The Aga Khan University, 2001. Thesis: Care and feeding practices and their association with stunting among young children residing in Karachi-s squatter settlementsThe Aga Khan University BBA (Management), The College of William and Mary, Williamsburg, VA, USA, 1989The College of William and Mary Research interest: Nutritional and behavioral epidemiology, methodological issues in dietary assessment methods, household food security and gender-related issues, care and feeding practices, management of data and questionnaire designing

3. Learning Objectives To understand the importance of establishing a cervical cancer screening programme To be familiar with the WHO recommended managerial factors to consider prior to setting up a screening programme To understand the concept of “downstaging” in terms of cervical cancer screening

4. Performance Objectives Know the managerial issues to consider when setting up a cervical screening program Understand the concept of downstaging and possible approaches of downstaging cervical cancer

5. Introduction Cervical cancer is the 2 nd most common cancer among women globally Higher cervical cancer mortality in developing countries due to lack of effective screening programs

6. Introduction High proportion of women are diagnosed at an advanced stage due to: –Lack of knowledge among women of the relevance of symptoms –Fatalistic attitude towards cancer and possibility of being cured –Lack of availability of health care in rural areas –Low priority of women’s health issues

7. Managerial factors to consider when setting up a screening programme – Formulation of screening programmes – The natural history of cervical cancer – Implications of screening policy – Service delivery – Information systems – Programme evaluation – Downstaging where cytological screening not possible

8. Natural History Cervical cancer develops slowly, and the key precursor is severe dysplasia. The natural history begins with –the onset of sexual activity at about age 13, –cervical dysplasia appears about age 18 through 35 years –Carcinoma in situ begins about age 35 years through to about age 50 when invasive cancers begin to appear as a prelude to death at about age 55.

9. Risk Factors identified Human papillomavirus (HPV DNA is present 93% of cervical cancer and its precursor lesions) – Epidemiologic studies ongoing on cofactors and host factors that may explain the natural history of HPV infections and their associated lesions. – Factors under investigation include smoking; use of hormonal contraceptives; number of live births; young age at first sexual intercourse; use of vitamins such as carotenoids, vitamin C, and folic acid; co-infection with other sexually transmitted diseases (e.g., herpes simplex, HIV, chlamydia); growth factors

10. Implementation and evaluation of cervical screening Decision to implement screening for cervical cancer should be based on: – Evidence that cervical cancer is a major health problem – Characteristics of individuals and populations at risk – An appropriate health service infrastructure – Technical resources for smear collection and cytological examination – Resources for diagnosis and treatment

11. Which health service sector? Decision on which health service sector to utilize for screening based on: Epidemiology Coverage of women at risk Use of maternal and child health / family-planning services Occupational health services Mobile units of screening Cost of screening in different health sectors

12. Frequency of screening Women with negative cervical smear have low rates of invasive cancer for 5 years. Also rates below those in general population for 10 or more years Cost-effective approach to recruit high proportion of the population and screen them infrequently rather than low proportion and frequent screening

13. Estimated reduction in the cumulative incidence of invasive cervical cancer in Chile as a result of a single screen at various ages Age of single screen % reduction in cum. incidence No. of tests in population (based on 1985 est pop. of Chile) 301188,000 351581,000 371781,000 402070,000 452657,000 502645,000 602134,000

14. Cost-effectiveness of two different strategies for cervical cancer screening in Chile Programme 1Programme 2 Age30-55 years30-50 years Frequency3-yearly10-yearly Compliance30%90% Reduction in mortality 15%44% Reduction in treatement costs US $0.13 millionUS $0.25 million Cost per case detected US $2,522US$556

15. Screening in Primary Health Care Setting up a screening service Target group Ensuring target group is screened Recording and reporting Management of women with abnormal smears

16. What is “downstaging” for cervical cancers Downstaging is the “detection of the disease in the earlier stage when still curable, by nurses and other non-medical health workers using a simple speculum for visual inspection of the cervix” visual inspection

17. Possible approaches to “downstaging” for cervical cancer Health education Restrict examination to women over 35 years Train female primary health workers to examine the cervix visually and to identify abnormalities Establish a link between identification of an abnormality and referral

18. Example of process and impact measures to monitor and evaluate downstaging: Process Measures –More than 80% of women in the 35-50 year target group are educated on cervical cancer. –More than 80% of primary health workers are educated and trained in visual examination of the cervix.

19. Example of outcome measures to monitor and evaluate downstaging: Outcome Measures –Short Term: More than one-third of cervical cancers are discovered by examination –Medium Term: There is more than a third reduction in cases presenting with advanced disease (Stage II and beyond). –Long Term: There is more than a third reduction in the mortality of cervical cancer.

20. Cancer Control Program A cancer control program is like a chair with four legs, a seat and a back. –Four legs represent: interventions or programs of prevention, screening, treatment and palliation. –Seat joins the four legs into a functional chair. It represents the organizational structure, management and governance of a national cancer control program that integrates its four programs into a functional unity. –Back of the chair provides support. Represents the infrastructure that needs to be in place for the four programs to function.

21. Online sources of interest The Merck Manual of Diagnosis and Therapy, Section 18. Gynecology And Obstetrics Chapter 241. Gynecologic NeoplasmsMerck Manual Cervical Cancer Screening Training ModulesTraining Modules MedlinePlus Health Information on cervical cancer MedlinePlus Reproductive Health Outlook (RHO) – cervical cancerRHO

22. Review Questions (Developed by the Supercourse team) What is the common cause of most cervical cancers diagnosed around the world? Describe the importance of cervical cancer screening. Why do developing countries have higher burden of cervical cancer mortality than developed countries?